Provider Demographics
NPI:1316962517
Name:LEVINE, KEITH A (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:LEVINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3180 N POINT PKWY
Mailing Address - Street 2:STE 207
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4381
Mailing Address - Country:US
Mailing Address - Phone:770-559-8725
Mailing Address - Fax:
Practice Address - Street 1:3180 N POINT PKWY
Practice Address - Street 2:STE 207
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4381
Practice Address - Country:US
Practice Address - Phone:404-446-2800
Practice Address - Fax:404-446-2809
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA0225832086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000244769CMedicaid
GA00244769AMedicaid
GA000244769CMedicaid
GAC46481Medicare UPIN